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Long NameDiagnosis Microscopic Pathology NCI Standard Template
DefinitionThe collection of CDEs used in the microscopic pathology module.
ContextcaBIG
Protocol Long NameNCI Standard Template Forms
WorkflowDRAFT NEW
TypeCRF
Public ID3918413
Version1.0
Module Long NameModule InstructionsQuestionCDECDE Public IDCDE VersionValue Domain Data TypeValue Domain Unit of MeasureDisplay FormatValid ValueForm Value Meaning TextForm Value Meaning Desc.
Optional Diagnosis Microscopic Pathology QuestionsThere is no requirement for inclusion of these elements on the case report form. If the design and scientific questions posed in the study dictate the need to collect this type of data, these elements should be included.
Lymphovascular invasion?Tumor Lymphovascular Invasion Disease Indicator39163271.0CHARACTER
YesYesYes, Missing for MC & VU
IndeterminateIndeterminateCannot distinguish between two or more possible values in the current context.
No SurgeryNo Surgical ProcedureThe non-affirmative response to a question.: A diagnostic or treatment procedure performed by manual and/or instrumental means, often involving an incision and the removal or replacement of a diseased organ or tissue; of or relating to or involving or used in surgery or requiring or amenable to treatment by surgery.
UnavailableNo Information AvailableInformation regarding the subject is unknown or inaccessible at this time.
NoNoThe non-affirmative response to a question.
Extramural venous invasion?Extramural Venous Invasion Disease Indicator39163281.0CHARACTER
YesYesYes, Missing for MC & VU
IndeterminateIndeterminateCannot distinguish between two or more possible values in the current context.
No SurgeryNo Surgical ProcedureThe non-affirmative response to a question.: A diagnostic or treatment procedure performed by manual and/or instrumental means, often involving an incision and the removal or replacement of a diseased organ or tissue; of or relating to or involving or used in surgery or requiring or amenable to treatment by surgery.
UnavailableNo Information AvailableInformation regarding the subject is unknown or inaccessible at this time.
NoNoThe non-affirmative response to a question.
Invasive component (Choose all that apply)Breast Cancer Invasive Histology Name20080412.0CHARACTER
Adenoid CysticAdenoid CysticAn adenoid cystic carcinoma primarily involving the breast. Three morphologic patterns are seen: cribriform, trabecular, and solid. The prognosis is excellent.
ADHAtypical Ductal Breast Hyperplasia A benign (not cancer) condition in which there are more cells than normal in the breast lobules and the cells look abnormal under a microscope. Having atypical lobular hyperplasia increases the risk of breast cancer.
ApocrineApocrineA glandular secreting cell in which the apical portion of the secreting cell is cast off along with the secretory products that have accumulated therein.
CA Cartilaginous OsseusCarcinoma with Cartilaginous/Osseous MetaplasiaAn invasive adenocarcinoma characterized by focal or extensive cartilage and/or bone formation.
CA Mixed MetaplasiaCarcinoma with Mixed MetaplasiaInvolving or composed of different kinds.: Transformation of a mature, normal cell or groups of mature cells to other forms of mature cells. The capacity for malignant transformation of metaplastic cells is a subject of controversy.: A malignant tumor arising from epithelial cells. Carcinomas that arise from glandular epithelium are called adenocarcinomas, those that arise from squamous epithelium are called squamous cell carcinomas, and those that arise from transitional epithelium are called transitional cell carcinomas. Morphologically, the malignant epithelial cells may display abnormal mitotic figures, anaplasia, and necrosis. Carcinomas are graded by the degree of cellular differentiation as well, moderately, or poorly differentiated. Carcinomas invade the surrounding tissues and tend to metastasize to other anatomic sites. Lung carcinoma, skin carcinoma, breast carcinoma, and prostate carcinoma are the most frequently seen carcinomas. -- 2004
CA Spindle Cell MetaplasiaCarcinoma with Spindle CellAn invasive adenocarcinoma of the breast usually affecting post-menopausal women, characterized by extensive spindle cell metaplasia of the neoplastic glandular cells.
CA Squamous MetaplasiaCarcinoma with Squamous MetaplasiaA morphologic finding indicating the transformation of glandular or transitional epithelial cells to, usually, mature squamous epithelial cells. Representative examples include squamous metaplasia of bronchial epithelium, cervix, urinary bladder, and prostate gland.: A malignant tumor arising from epithelial cells. Carcinomas that arise from glandular epithelium are called adenocarcinomas, those that arise from squamous epithelium are called squamous cell carcinomas, and those that arise from transitional epithelium are called transitional cell carcinomas. Morphologically, the malignant epithelial cells may display abnormal mitotic figures, anaplasia, and necrosis. Carcinomas are graded by the degree of cellular differentiation as well, moderately, or poorly differentiated. Carcinomas invade the surrounding tissues and tend to metastasize to other anatomic sites. Lung carcinoma, skin carcinoma, breast carcinoma, and prostate carcinoma are the most frequently seen carcinomas. -- 2004
Carcinoma NOSCarcinoma, NOS (Not Otherwise Specified)A malignant tumor arising from epithelial cells. Carcinomas that arise from glandular epithelium are called adenocarcinomas, those that arise from squamous epithelium are called squamous cell carcinomas, and those that arise from transitional epithelium are called transitional cell carcinomas. Morphologically, the malignant epithelial cells may display abnormal mitotic figures, anaplasia, and necrosis. Carcinomas are graded by the degree of cellular differentiation as well, moderately, or poorly differentiated. Carcinomas invade the surrounding tissues and tend to metastasize to other anatomic sites. Lung carcinoma, skin carcinoma, breast carcinoma, and prostate carcinoma are the most frequently seen carcinomas. -- 2004
CIS NOSCarcinoma in Situ, NOSA malignant epithelial neoplasm which is confined to the epithelial layer without evidence of further tissue invasion.
Comedo/MucinousComedo/MucinousComedo; having a black or dark core or plug.: containing or resembling mucin.: The study of the structure of the cells and their arrangement to constitute tissues and, finally, the association among these to form organs. In pathology, the microscopic process of identifying normal and abnormal morphologic characteristics in tissues, by employing various cytochemical and immunocytochemical stains.
CribiformCribiformCribriform; having the appearance of a sieve: containing many perforations.
Ductal CarcinomaDuctal Breast CarcinomaA carcinoma arising from the ducts. While ductal carcinomas can arise at other sites, this term is universally used to refer to carcinomas of the breast. Ductal carcinomas account for about two thirds of all breast cancers. Two types of ductal carcinomas have been described: Ductal carcinoma in situ (DCIS) and invasive ductal carcinoma, not otherwise specified. The latter often spreads to the axillary lymph nodes and other anatomic sites. The two forms of ductal carcinoma often coexist.
Ductal CISDuctal CISA carcinoma entirely confined to the mammary ducts. It is also known as DCIS. There is no evidence of invasion of the basement membrane. Currently, it is classified into three categories: High-grade DCIS, intermediate-grade DCIS and low-grade DCIS. In this classification the DCIS grade is defined by a combination of nuclear grade, architectural growth pattern and presence of necrosis. The size of the lesion as well as the grade and the clearance margins play a major role in dictating the most appropriate therapy for DCIS.
Ductal HyperplasiaUsual Ductal Breast Hyperplasia A neoplastic ductal proliferative lesion of the breast characterized by the formation of secondary lumens and prominent intraductal proliferation of a heterogeneous cellular population that may include epithelial cells, myoepithelial cells, or metaplastic apocrine cells.
Extensive Ductal CISExtensive Ductal Carcinoma in situLarge in quantity, range, or spatial extent.: A carcinoma entirely confined to the mammary ducts. It is also known as DCIS. There is no evidence of invasion of the basement membrane. Currently, it is classified into three categories: High-grade DCIS, intermediate-grade DCIS and low-grade DCIS. In this classification the DCIS grade is defined by a combination of nuclear grade, architectural growth pattern and presence of necrosis. The size of the lesion as well as the grade and the clearance margins play a major role in dictating the most appropriate therapy for DCIS.
Infiltrating DuctalInfiltrating Ductal CarcinomaInvasive ductal carcinoma is the most common type of invasive breast carcinoma (accounting for approximately 70% of breast carcinomas). The gross appearance is usually typical with an irregular stellate outline. Microscopically, randomly arranged epithelial elements are seen. When large sheets of malignant cells are present, necrosis may be seen. With adequate tissue sampling, in situ carcinoma can be demonstrated in association with the infiltrating carcinoma. The in situ component is nearly always ductal but occasionally may be lobular or both. --2002
Infiltrating LobularInfiltrating Lobular CarcinomaAn infiltrating lobular adenocarcinoma. The malignant cells lack cohesion and are arranged individually or in a linear manner (Indian files), or as narrow trabeculae within the stroma. The malignant cells are usually smaller than those of ductal carcinoma, are less pleomorphic, and have fewer mitotic figures. --2002
Lobular CarcinomaLobular Breast CarcinomaAn adenocarcinoma of the breast arising from the lobules. This is a relatively uncommon carcinoma, represents approximately 10% of the breast adenocarcinomas and is often bilateral or multifocal.
Lobular NeoplasiaLobular NeoplasiaA spectrum of non-invasive neoplastic lesions that arise from the terminal ductal lobular units of the breast. There is atypical small epithelial cell proliferation. Pagetoid involvement of the terminal ducts may or may not be present. In the minority of cases, there is a risk for subsequent development of invasive ductal or invasive lobular carcinoma.
Medullary CarcinomaMedullary Breast CarcinomaAn infiltrating breast carcinoma distinguished by its allegedly good prognosis. Medullary breast carcinoma is uncommon, accounting for fewer than 1% of all infiltrating breast carcinomas. Grossly, this is a well circumscribed tumor, with soft cut surface
Mixed ductal/lobularMixed ductal/lobularMixed ductal/lobular
MucinousMucinous adenocarcinomaAn invasive adenocarcinoma composed of malignant glandular cells which contain intracytoplasmic mucin. Often, the infiltrating glandular structures are associated with mucoid stromal formation. It may arise from the large and small intestine, appendix, stomach, lung, ovary, breast, corpus uteri, cervix, vagina, and salivary gland.
NoneNoneNo person or thing, nobody, not any.
Not PresentNot PresentValue is not present in a message. This is only defined in messages, never in application data! All values not present in the message must be replaced by the applicable default, or no-information (NI) as the default of all defaults.
OtherOtherNot otherwise specified.
Paget DiseasePaget DiseaseA malignant neoplasm composed of large cells with large nuclei, prominent nucleoli, and abundant pale cytoplasm (Paget cells). Paget's cell neoplasms include Paget's disease of the nipple and extramammary Paget's disease which may affect the vulva, penis, anus, skin and scrotum. -- 2004
Papillary CarcinomaPapillary Breast CarcinomaA malignant breast neoplasm characterized by the formation of irregular, finger-like projections of fibrous stroma covered with neoplastic epithelial cells.
Poorly Differentiated NOSPoorly Differentiated, Not Otherwise SpecifiedPoorly Differentiated, Not Otherwise Specified
SecretorySecretoryA rare, low grade invasive adenocarcinoma of the breast characterized by the presence of cells that secrete milk-like material. Morphologically, it usually appears as a circumscribed lesion, composed of cystic spaces, tubular structures, and solid areas.
TubularTubular AdenocarcinomaAn aggressive adenocarcinoma that arises from the sweat glands. It usually presents as a firm, erythematous nodular lesion in the axilla. Morphologically, it is characterized by the presence of tubular structures and apocrine differentiation.
Perineural invasion?Perineural Tumor Cell Invasion Indicator39163441.0CHARACTER
YesYesYes, Missing for MC & VU
No SurgeryNo Surgical ProcedureThe non-affirmative response to a question.: A diagnostic or treatment procedure performed by manual and/or instrumental means, often involving an incision and the removal or replacement of a diseased organ or tissue; of or relating to or involving or used in surgery or requiring or amenable to treatment by surgery.
IndeterminateIndeterminateCannot distinguish between two or more possible values in the current context.
UnavailableNo Information AvailableInformation regarding the subject is unknown or inaccessible at this time.
NoNoThe non-affirmative response to a question.
Mitotic CountNottingham Mitotic Count Grade24315552.0CHARACTER
UNot Stated UnknownNot provided or available.: Not known, not observed, not recorded, or refused.
1less than 10 mitoses per 10 high HPF (25X objective) or 0 to 5 mitoses per 10 HPF (40X objective)For a 25X objective with a field area of 0.274 mm squared: a score of 1 indicates less than 10 mitoses per 10 high power feilds. For a 40X objective with a field area of 0.152 mm squared: a score of 1 indicates 0 to 5 mitoses per 10 high power fields power fields.
210-20 mitoses per 10 high power fields (25X objective) or 6 to 10 mitoses per 10 high power fields (40X objective)For a 25X objective with a field area of 0.274 mm squared: a score of 2 indicates 10-20 mitoses per 10 high power fields. For a 40X objective with a field area of 0.152 mm squared: a score of 2 indicates 6 to 10 mitoses per 10 high power fields.
3Greater than 20 mitoses per 10 HPF (25X objective) or greater than 10 mitoses per 10 HPF (40X objective)For a 25X objective with a field area of 0.274 mm squared: a score of 2 indicates 10-20 mitoses per 10 high power fields. For a 40X objective with a field area of 0.152 mm squared: a score of 2 indicates 6 to 10 mitoses per 10 high power fields.
Nuclear pleomorphismHistologic Nottingham Score Nuclear Pleomorphism Grade3503.0CHARACTER
Grade I (low, 1 pt)small regular nucleismall regular nuclei
Grade II (intermediate, 2 pts)Moderate increase in size, etcModerate increase in size, etc
Grade III (high, 3 pts)Marked variation in size, nucleoli, chromatin clumping, etcMarked variation in size, nucleoli, chromatin clumping, etc
NonTumor Premalignant HistologyAssociated Premalignant Change(s) Yes No Indicator39182121.0CHARACTER
YesYesThe affirmative response to a question or activity.
NoNoThe non-affirmative response to a question.
Associated Pre-Malignant Histologic ChangesAssociated Premalignant Change Type21823361.0CHARACTER
1Basal Cell HyperplasiaBasal Cell Hyperplasia
2Basal Cell Hyperplasia with Angiogenic Squamous Dysplasia changesBasal Cell Hyperplasia with Angiogenic Squamous Dysplasia changes
3Squamous MetaplasiaSquamous Metaplasia
4Squamous Metaplasia with Angiogenic Squamous Dysplasia changesSquamous Metaplasia with Angiogenic Squamous Dysplasia changes
5Carcinoma in SituA malignant epithelial neoplasm which is confined to the epithelial layer without evidence of further tissue invasion.
6Atypical Adenomatous HyperplasiaAtypical Adenomatous Hyperplasia
7Mild DysplasiaMild Dysplasia
8Mild Dysplasia with Angiogenic Squamous Dysplasia changesMild Dysplasia with Angiogenic Squamous Dysplasia changes
9Moderate DysplasiaModerate Dysplasia
10Moderate Dysplasia with Angiogenic Squamous Dysplasia changesModerate Dysplasia with Angiogenic Squamous Dysplasia changes
11Severe DysplasiaSevere Dysplasia
12Severe Dysplasia with Angiogenic Squamous Dysplasia changesSevere Dysplasia with Angiogenic Squamous Dysplasia changes
13Other, specify:Other, specify:
Other, specifyAssociated Specimen Premalignant Histologic Change Specify643004.0CHARACTER
Description of Tumor Border ConfigurationTumor Border Type642093.0CHARACTER
IndeterminateIndeterminateCannot distinguish between two or more possible values in the current context.
InfiltratingINFILTRATINGINFILTRATING
OtherOtherNot otherwise specified.
PushingPUSHINGPUSHING
Other specifyTumor Border Specify642103.0CHARACTER
Percent of Cancer in SpecimenPositive Malignant Neoplasm Specimen Percentage Value650843.0NUMBER%
Intratumoral/Peritumoral Lymphocyte ResponseIntratumor Peritumoral Lymphocytic Response Status39182441.0CHARACTER
NoneNoneNo person or thing, nobody, not any.
Marked (including Crohn-like response)Marked ResponseA prominent or noticeable characteristic.: Response; a bodily process occurring due to the effect of some foregoing stimulus or agent.
Mild to moderateMild Moderate ResponseGentle or temperate in nature or degree.: The quality of being within reasonable or average limits; not excessive or extreme.: Response; a bodily process occurring due to the effect of some foregoing stimulus or agent.
Prostatic Intraepithelial Neoplasia (PIN)Specimen Prostatic Intraepithelial Neoplasia Status39182551.0CHARACTER
NoneNoneNo person or thing, nobody, not any.
Not AssessedNot TestedIndicates that a test was not performed.
Low GradeLow Grade Prostatic Intraepithelial NeoplasiaProstatic intraepithelial neoplasia characterized by the proliferation of secretory cells with irregular spacing in the ducts and acini. Although some proliferating epithelial cells may contain prominent nucleoli, the cytologic atypia and architectural growth patterns that are seen in the high grade prostatic intraepithelial neoplasia are absent. The presence of low grade prostatic intraepithelial neoplasia in needle biopsy is not a risk factor for the subsequent detection of carcinoma on repeat biopsy.
High GradeHigh Grade Prostatic Intraepithelial NeoplasiaProstatic intraepithelial neoplasia characterized by the presence of morphologically malignant cells lining the acini and ducts. The malignant cells are enlarged, contain prominent nucleoli, and have increased nuclear/cytoloplasmic ratio. The malignant cells may grow within the ducts and acini in four architectural patterns: flat, tufting, micropapillary, and cribriform. The presence of high grade prostatic intraepithelial neoplasia in needle biopsy is a risk factor for the subsequent detection of carcinoma on repeat biopsy.
Present, NOSNot Otherwise Specified PresentNot characterized in any other way.: Being or existing in a specified place or at the specified time.
Pelvic Lymph Node Dissection (PLND)Pelvic Lymph Node Dissection Result Positive Negative Not Done Category39182631.0CHARACTER
NegativeNegative FindingA finding of normality following an examination or investigation looking for the presence of a microorganism, disease, or condition.
PositivePositive FindingAn observation confirming something, such as the presence of a disease, condition, or microorganism.
Not DoneNot DoneIndicates a task, process or examination that has either not been initiated or completed.
Tubule FormationNottingham Histopathologic Grade Tubule Formation Score Integer24315531.0NUMBER
1Majority of tumor (greater than 75%)Majority of tumor (greater than 75%)
2Moderate (10% to 75%)Moderate (10% to 75%)
3Minimal (less than 10%)Minimal (less than 10%)